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f;ppzAp JOAQUIN LOCAL HEALTH DISTRIC7--� <br /> FOTO*OFFICE USE: 10 ,E. Hazelton Ave. , Stockton, Ca..4._i . <br /> Telephone: (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,4-- L� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7-2-24�F <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Jonquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 23252 So. Jlive Ripon, Cal CENSUS TRACT <br /> Owner's Name Arthus cststeyn Phone 599-3193 <br /> Address 2256a South Highland City Ripon, Cal <br /> Contractor's Name g - <br /> Henni s Bros . DrilJ_ing Co. , Inc. License # 20813 Phone 52`1031. <br /> 2500 West Rumble Rd: MoFles „ul .. Ca 95350 <br /> TYPE OF WORK (Check) : NEW WELL/'/ DEEPEN '/ / RECONDITION /7 DESTRUCTION <br /> PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT /_7AL <br /> Other / / 0 <br />' .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �J <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing w <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ; ! n <br /> Cathodic Protection X Rotary Type of Grout _ Bentonite V <br /> Disposal Other Other Information Slab. by owner <br /> Geophysical Surface Seal Installed 'By: Driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '-construction. Within FIF=TEEN DAYS <br /> atter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well. in use.... The above <br /> information_ is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO_TgWUTIN.G <br /> AND A FI PE ION. <br /> SIGNED ri° TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r C/f.. DATE /W '�? _ <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT .INSPECTION P I AL INSPECTI <br /> INSPECTION BY ri DATE INSPECTION B DATE! �C <br /> - �� <br /> E H 1426 Rev. 1-74 2�r � l�zca��' t. ��� •,z, <br />